Provider Demographics
NPI:1881844587
Name:MAZZITELLO, JOHN ALLAN (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ALLAN
Last Name:MAZZITELLO
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1415
Mailing Address - Country:US
Mailing Address - Phone:320-252-5938
Mailing Address - Fax:320-252-5938
Practice Address - Street 1:1700 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1415
Practice Address - Country:US
Practice Address - Phone:320-252-5938
Practice Address - Fax:320-252-5938
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN170001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical